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GASTROINTESTINAL MALIGNANCIES
Initial Phase (20 years or more)
Esophageal CA • Basal cell hyperplasia
• Various degrees of hyperplasia
Epidemiology -mild dysplasia develop SCC
• No other cancer whose incidence varies within -14.9% of severe dysplasia developed SCC in 1-
countries as much as esophageal CA 12 years
• Half of all cases in China
• Equal male:female ratio in endemic areas Developing Phase (33.9 to 74 months)
• Squamous cell CA and adenocarcinoma more • When severe dysplasia become early carcinoma
than 95% of esophageal tumors
Overt Phase
• 6th-7th decade of life
• Mean survival time 9.7 months
Risk factors and Pre-existing conditions associated with
Clinical Manifestations
Squamous Cell Carcinoma
• Vague retrosternal discomfort
• Dietary (N-nitroso compounds, alcohol
(liquor>beer), hot tea, tannins) • Dysphagia
• Tobacco • Food intolerance
• Betel nut chewing • Anorexia
• Chronic strictures (lye, radiation) • Weight loss
• Chronic infection (fungal, viral) • Odynophagia and back pains
• Chronic esophagitis • Hoarseness
• History of head and neck malignancy • Hematemesis
• Achalasia
Diagnostic Evaluation
• Plummer-Vinson syndrome
• Tylosis Laboratory Data
• Celiac disease • Microcytic anemia
• History of gastrectomy • Low serum albumin
• History of radiation therapy • Elevated ALP
• Hypercalcemia
Pathology
• Low cholesterol
• Most common site: middle esophagus
• CA 19-9 (34% sensitivity)
• Early: barely perceptible to tiny, slightly elevated
coarse or polypoid with denuded epithelium Balloon cytology
• Histologic: intraepithelial, intramucosal,
submucosal
• Only 8-12% of SCC lesions diagnosed early
• Only 2.2% of early SCC limited to musculartis
mucosa (88.4% vs. 54.5% sub,ucosal 5 year-
survival)
• Advanced SCC: mushroom-like, ulcerative,
stenotic polypoid
MARY YVETTE ALLAIN TINA RALPH SHERYL BART HEINRICH PIPOY KC JAM CECILLE DENESSE VINCE HOOPS CES XTIAN LAINEY RIZ KIX EZRA GOLDIE BUFF MONA AM MAAN ADI KC
PENG KARLA ALPHE AARON KYTH ANNE EISA KRING CANDY ISAY MARCO JOSHUA FARS RAIN JASSIE MIKA SHAR ERIKA MACKY VIKI JOAN PREI KATE BAM AMS HANNAH MEMAY PAU
RACHE ESTHER JOEL GLENN TONI
Subject: Medicine 2
Topic: GI Malignancies and Emergencies
Page 2 of 11
T2 Tumor invades muscularis propia
T3 Tumor invades adventitia
T4 Tumor invades adjacent structures
Stage Grouping
Stage O TisNoMo
Stage I T1NoMo
Stage IIA T2NoMo
TsNoMo
Stage IIB T1N1Mo
T2N1Mo
Stage III T3N1Mo
Polypoid carcinoma in mid-esophagus (Barium swallow) T4AnyNMo
Stage IV AnyTAnyNM1
5 Year Survival
• I: 60.4%
• II:31.3%
• III:19.9%
• IV:4.1%
Treatment Modalities
• Surgery
• Radiation
• Chemotherapy
• Multimodality
-preoperative radiotherapy
-preoperative chemotherapy
-preoperative chemoradiation
-preoperative radiotherapy, chemotherapy
• Endoscopic modality
Primary Tumor
Benign
•Polyps
•Hyperplastic
Celestin semi-rigid esophageal dilators •Fundic gland
•neoplastic
•multiple tumors
•leiomyomas
•lipomas
•heterothropic pancreas
Malignant Tumors
•Carcinomas
•Lymphomas
•Sarcomas
•Carcinoids
Following balloon dilatation, wasting is effaced
Gastric Polyps
Hyperplastic polyps
•Most common type of polyp(65-90%)
•Inflammatory or regenerative polyps in reaction to
chronic inflammation or regenerative hyperplasia
•Often found in HP infection
•Sessile and seldom pedunculated
•Mostly in the antrum
•Multiple in 50% of cases
Expandable metal stent on an inoperable carcinoma •Varying in size but seldom <2cm
•Rate of malignant transformation 1-3%
Esophageal AdenoCA •Usually larger than 2 cm
Treatment
•Endoscopic removal if no malignancy identified with
surveillance
•Excision with malignant focus or were the endoscopic
removal failed
Risk Factors for Gastric CA
Multiple Gastric Polyps
Precursor conditions:
•Chronic atropic gastritis and intestinal metaplasia •Rare condition
•Pernicious anemia •Adenomatous and hyperplastic polyps
•Partial gastrectomy for benign disease •20% incidence of adenocarcinoma
•H. pylori infection
•Menetrier’s disease Treatment
Subject: Medicine 2
Topic: GI Malignancies and Emergencies
Page 4 of 11
•If confined to corpus and antrum- distal gastrectomy •Involvement of fundus and cardia
•If otherwise total gastrectomy
•Sometimes associated with polyposis syndrome Gastric Leiomyoma
•FAP
•Gardner •Incidence of 16% In autopsy
•Peutz-Jeghers
Pathology
•Cowdens
•Arise from the smooth muscle of the GIT tract
•Cronkhite Canada
•Difficult to distinguished from GIST
Gastric Lipoma •75% benign
•Differentiated only by mitotic index
•Rare subcutaneous lesions •Large protruding lesions with central ulcers
•Asymptomatic •Usually presents with bleeding if at all
•On routine endoscopy •Treatment Is local excision with 2-3cm margins
•Requires no treatment
Histologic typing
•Pillow sign
Ulcerated carcinoma (25%)
Heterotropic Pancreas •Deep penetrated ulcers with shallow edges
•Usually through all layers of the stomach
•Extopic pancreas
PolypoidCa(25%)
•Most commonly found in the stomach
•Intramural tumors, large in size
•Within 6 cm from the pylorus
•Late metastasis
•Also in meckel’s diverticulum
•Rarely larger than 4 cm
Superficial spreading Ca( 15%)
•Sessile and rubbery •Confinement to mucosa and submucosa
•Submucosal in location •Metastasis 30% at time of diagnosis
•Histological identity similar to normal pancreas •Better prognosis stage for stage
Malignant Linitis Plastica
•Peri-ampullar adeno Ca
•Duodenum •Varity of SS but involves all layers of the stomach
•Cholangio •Early spread with poor prognosis
•Pancreatic head Advance Ca (30%)
•Leiomyosarcomas •Partly within and outside the stomach
•Lymphomas •Represent the advanced stage of most of the
forementioned ca
Risk Factors for Gastric CA
Symptoms and signs
•Genetic and environmental Factors: •Vague discomfort difficult to distinguish from dyspepsia
o Family history of Gastric Ca •Anorexia
o Blood type A •Meat aversion
o Hereditary nonpolyposis colon Ca syndrome •Pronounced weight loss
o Low socio economic status
o Low consumption of fruits and vegetables At late stage
o Consumption of smoked, salted, poorly preserved •Epigastric mass
foods •Hematemesis usually coffee ground seldom severe
o Cigarette smoking
•Metastasis
Adenocarcinoma of the Stomach •Virchow node on the neck
•Blumer shelf in rectum
•Declining incidence In the western world
Gastric Lymphoma
•HP associated due to chronic atropic gastritis
•Also related to Low dietary intake of vegetables and
•5% of all neoplastic gastric neoplasm
fruits
•2 different types of lymphoma
•High dietary intake of starches
•Part of systemic lymphoma with gastric involvement
•Common in male (3:1)
(32%)
•Histology
•Part of primary involvement of GIT(MALT tumor)
•Invariably adeno-carcinoma
•10-20% of all lymphoma occurs in the abdomen
•SCC of the oesophagus
Subject: Medicine 2
Topic: GI Malignancies and Emergencies
Page 5 of 11
•50% of those are gastric in nature Gastric CA
Treatment controversial
Surgical treatment for patients without systemic
involvement
•Mandatory for high grade lesions
•Possible not needed for low grade tumor
•Total gastrectomy and en-block for direct involvement
•Sparing duodenum and oesophagus
Palliative Resection with intra abdominal spread Barium swallow polypoid carcinoma
•Good for bleeding, obstruction and perforations
•Radiation and chemotherapy combination for most
Gastric Sarcoma
Gastric Lymphoma
Colonic CA
5-year Management
Apple-core Stricture of Colonic Carcinoma surviva
l after
treatm
ent (%)
A Cancer limited to 90 Polypectomy/en
mucosa or bloc resection
submucosa
B Cancer penetrates 80 En bloc
1 into but not thru resection/ ?
muscularis propia Adjuvant
B Cancer penetrates 70 Chemotx
2 thru muscularis
propia or serosa
C B1 + LN 50 En bloc
1 metastases resection/ ?
C B2 + LN 50 Adjuvant
2 metastases Chemotx
Different Patterns of Colonic Adenomatous Polyps
D Distant <30 Palliative
Subject: Medicine 2
Topic: GI Malignancies and Emergencies
Page 9 of 11
metastases surgery, treat 3. Know underlying pathology
metastatic 4. Know treatment strategy
disease
Acute GI Emergencies
Random False-Negative Rate
Classify the site
FOBT 40
%
Sigmoidoscopy 15
%
Colonoscopy 05
%
Air Contrast BE 15
%
Single Column BE 30
1.
%
Esophagus – acute dysphagia
Diet for FOBT Perfusion
Bleeding
Avoid: Stomach/duodenum
- Red meat Perfusion
- Aspirin, NSAIDs Bleeding
- Peroxidase-containing foods (turnips, horse 2.
radish) Gallbladder/Biliary Tract
- Vitamin C, citrus juices (false negative) Cholecystitis
- Iron-containing drugs (false positive) Cholangitis
Obstructive jaundice
Poor Prognostic Features in Colorectal CA
Pancreas
• Increased depth of bowel wall penetration Acute pancreatitis
3.
• >4 nodes involved in tumor
Small intestine
• Poorly differentiated tumor
Intestinal obstruction
• Mucinous or signet-ring histology
Mesenteric infarct
• Scirrhous histology
(infectious diarrhea)
• Venous invasion Crohn’s disease
• Lymphatic invasion Meckel’s Diverticulum
• Perineural invasion 4.
• Aneuploidy Large Bowel (+App)
• Bowel obstruction Acute appendicitis
• Bowel perforation Acute diverticulitis
• ? rectum Lower GI bleeding
• ? right colon Perforation
***oo, may question marks talaga ung nasa slide ni Intestinal obstruction
doc Uncontrolled ulcerative colitis
• Age <30 5.
• High CEA level Peritoneal cavity
• Deletions in chromosomes 18q or 17p Peritonitis
• Distant metastasis Intra-abdominal abscess
III. Perforation
High Mortality
• May folloe
endoscopy
• Presentation- acute
Gallbladder/Biliary Tract
chest/abdominal
pain
I. Obstructive Jaundice
• Air in mediastinum
• Yellow skin, sclera
and soft tissues
• Pale stools, dark urine
• Treatment:
surgery- benign • +/- pain
intubation- • +/- Courvoisier’s sign
malignant • CT: dilated bile ducts
• Establish diagnosis: gallstones, CA head of pancreas
• Appropriate treatment
Small Intestine
I. Meckel’s Diverticulum
Rare
• Diverticulum of terminal
ileum
• Can be lined by gastric
epithelium
• Can perforate
Subject: Medicine 2
Topic: GI Malignancies and Emergencies
Page 11 of 11
• Can present like appendicitis • Underlying pathology
• Treatment strategy
II. Intestinal Obstruction
• May arise due to adhesions, hernia, tumor
• Presentation: colicky abdominal pain, vomiting,
constipation
• Treatment: resusciatate/operate
Large Bowel
I. Acute Diverticulitis
• Maximal in L colon
• Presentation: LIF pain, fever, tenderness,
leukocystosis
• Middle aged or elderly
• Treatment: conservative antibiotics, fluids, bed rest
III. Perforation
• Diverticulum, colitis, sudden severe abdominal pain,
rigidity
• Fecal peritonitis
• Pyrexia, shock
• Free gas on x-ray
• Treatment: resuscitate, operate
V. Ulcerative Colitis
• Presents: bloddy diarrhea, pyrexia, leukocytosis, may
develop toxic megacolon
• Treatment: steroids, surgery on failure
Peritoneal Cavity
I. Acute Peritonitis
• Any perforation, pancreatitis, abdominal pain,
tenderness, guarding, silent abdomen, shock
• Treatment: underlying condition
Conclusion